Insurance Premium Indication Form

Name Insured:
Contact Person:
Location Address:
City:      State:      Zip Code:
Phone Number:
Email Address:


License Capacity:      Avg. Daily Attendance:      # of Teachers:
1. This day care center is located in which type of building?
Other:
2. What are your hours of operation?
3. Any overnight stays? Yes No
4. Do you provide sick child, drop in, latch-key, boarding or camp services? Yes No
If yes, please explain:
5. Do you now use, or plan in the future to use, swimming facilities? Yes No
6. Is the play area fenced? Yes No
7. Are any pets or animals kept on premises? Yes No
8. Are special classes provided? Yes No
(Gymnastics, Dance, Karate, Tumbling, Horseback Riding, etc.)
9. What limit do you want quoted for sexual molestation coverage?
$100,000/300,000 $1,000,000/2,000,000
10. Does your employment application include questions about whether the individual has ever been convicted of any crime, including sex-related or child abuse offenses? Yes No
11. During new staff orientation, do you discuss child/sexual abuse, how to recognize the signs, and what to do if a child reports that someone molested him or her? Yes No
12. Do you perform criminal background investigations on all current employees and volunteers?
Yes No
13. Have you ever had an incident which resulted in an allegation of sexual abuse?
Yes No
If yes, please explain:
14. What limit do you want to insure your building?
15. What limit do you want to insure your contents?
16. What limit do you want to insure your play equipment?
17. Is the building? Free Standing Multiple Occupancy
18. What year was the building built?
19. Is your building? Frame Brick Cinder Block Other:
20. What is the square footage of your building?
21. Do you have commercial autos you want to insure? Yes No
If yes, please provide the following:
Year: Make: Model:
VIN:
Year: Make: Model:
VIN:

Note: This form is not an offer to purchase insurance. It is designed to give you a nonbinding indication of the premium you may be eligible for. Additional information may be needed such as detailed loss history and other information.

Fraud Notice

Notice to applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime and may subject such person to criminal and civil penalties.

Notice to New York Applicants: Any person who knowingly and with intent to defraud any insurance company other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the state value of the claim for each such violation.

Notice to Kentucky Applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime.

Notice to Minnesota and Ohio Applicants: Any person, who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Notice to Nebraska and Oklahoma Applicants: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Notice to Pennsylvania Applicants: Any person who knowingly and with intent to defraud any insurance company other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance act which is a crime and subjects such person to criminal and civil penalties.

Notice to Florida Applicants: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Notice to New Jersey Applicants: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Notice to Maine and Virginia Applicants: It is a crime to knowingly provide false information, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Notice to Oregon Applicants: Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact, may be violating state law.

Notice to District of Columbia Applicants: "Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant."

Notice to New Mexico Applicants: "Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties."

Notice to Tennessee Applicants: "It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits."